|Year : 2019 | Volume
| Issue : 1 | Page : 10-14
Gastric outlet obstruction in adults in the University of Benin Teaching Hospital: A 5-year prospective study
Peter Ikponmwosa Agbonrofo, Omorodion O Irowa, Vincent I Odigie
Department of Surgery, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||15-Oct-2019|
Dr. Peter Ikponmwosa Agbonrofo
Department of Surgery, University of Benin Teaching Hospital, PMB 1111, Benin City
Source of Support: None, Conflict of Interest: None
Background: Gastric outlet obstruction (GOO) is a contemporary surgical challenge. It is due to mechanical pyloroduodenal obstruction of gastric emptying. In Africa, cicatrizing duodenal ulcer or antral tumors are common causes; resultant inanition, fluid, electrolyte, and nutritional derangements could be life-threatening. Definitive therapy aims at relieving the obstruction. Aim: To highlight causes, clinical features, and outcome of management of GOO in the University of Benin Teaching Hospital. Patients and Methods: This was a 60-month prospective study from July 1, 2013, to June 30, 2018. Consecutive adult patients with GOO were studied. Diagnosis was confirmed using barium meal, esophago-gastro-duodenoscopy, biopsy, and operative findings. Preoperative optimization required nasogastric tube suctioning/warm saline lavage, intravenous fluids, antibiotics, and blood transfusion. Results: There were 52 GOO patients, constituting 7.9% of 659 gastrointestinal conditions requiring surgery during the study period. Operative intervention occurred in 50 (96.2%) patients. The male:female ratio was 1.7:1. The age ranges from 32 to 89 years, with a mean age of 63.5 ± 15.3 years. Most patients were in the 7th-8th decades of life (33 patients, 63.5%). Nonbilous vomiting and epigastric pain occurred in 50 (96.2%) patients, while 49 (94.2%) patients had weight loss. Mean duration of symptoms 10.5 ± 12.1 weeks. Malignant obstructions were 63.5% (33 patients). Palliative by-pass was effected in 58.0% (29 patients). Hospital stay was 16–23 days. Mortality rate was 3.8% (2 patients). Conclusions: GOO is a disease of the elderly in our region. Presentation is late. Most require surgical intervention. The most common cause is malignant obstruction. Most patients require prolonged, adequate preoperative resuscitation/optimization. We advocate early referral, routine endoscopy, and biopsy for patients with epigastric pain in the subregion.
Keywords: Antral cancer, cicatrized duodenal ulcer, endoscopy, gastric outlet obstruction, University of Benin Teaching Hospital
|How to cite this article:|
Agbonrofo PI, Irowa OO, Odigie VI. Gastric outlet obstruction in adults in the University of Benin Teaching Hospital: A 5-year prospective study. Arch Med Surg 2019;4:10-4
|How to cite this URL:|
Agbonrofo PI, Irowa OO, Odigie VI. Gastric outlet obstruction in adults in the University of Benin Teaching Hospital: A 5-year prospective study. Arch Med Surg [serial online] 2019 [cited 2020 Jul 4];4:10-4. Available from: http://www.archms.org/text.asp?2019/4/1/10/269233
| Introduction|| |
Gastric outlet obstruction (GOO) is a contemporary surgical challenge that may arise from several pathologic entities.,,,,,, It is usually as a result of mechanical obstruction at the pyloroduodenal region, preventing adequate gastric emptying. In Africa, cicatrizing duodenal ulcer or antral tumors are common causes., Nonbilous vomiting, epigastric pain, and weight loss are the common features in patients with GOO.,,,, They may present with severe fluid, electrolyte, and nutritional abnormalities, which could be life-threatening., Definitive therapy aims at relieving the obstruction. Treatment options depend on the etiology and include vagotomy and drainage procedures; gastrojejunostomy alone or in conjunction with partial gastrectomy; and endoscopic stenting.,
This study was carried out to highlight the causes, clinical features, and management outcome of GOO as seen in a tertiary, referral hospital University of Benin Teaching Hospital (UBTH), in the south-south region of Nigeria.
| Patients and Methods|| |
It was a 60-month prospective study (July 1, 2013, to June 30, 2018) of all consecutive adult patients with GOO, who presented to surgery outpatient clinic and emergency room of UBTH. Informed consent for the study was obtained from all the patients. Data including bio-data, clinical presentation, laboratory/contrast studies/esophago-gastro-duodenoscopy, operative findings, and biopsy (endoscopic/intraoperative) results were entered into a pro forma. Patients had preoperative optimization via nasogastric tube suctioning, warm saline lavage, intravenous fluids, antibiotics, and blood transfusion. All patients who had failed nonoperative management (persistent nonbilous vomiting/nonbilous nasogastric tube effluent and epigastric pain) were subjected to surgical intervention. Data were analyzed using IBM corporation Statistical Package for the Social Sciences (SPSS) statistics for windows, version 21.0. Armonk, New York, United States of America.
UBTH is a tertiary, referral hospital in the south-south region of Nigeria. Her catchment area spans the Niger-Delta region; our experience may therefore be a reflection of the disease pattern in this subregion.
| Results|| |
Fifty-two patients had GOO during the study period. This constituted 7.9% of 659 gastrointestinal conditions requiring surgery, during the study period. The average incidence was found to be 10 cases/year.
Fifty patients (96.2%) required operative intervention, and only two patients (3.8%) were successfully managed nonoperatively.
Age and sex distribution of gastric outlet obstruction patients
The male:female ratio was 1.7:1. The age range was 32–89 years. The mean age of the patients was 63.5 ± 15.3 years. The mean age for males was 65 ± 14.1 years while the mean age for females was 62.9 ± 11.8 years.
The cluster age distribution was 7th–8th decade (33 patients, 63.5%) [Figure 1]. Female cluster was one decade younger (6th–7th decade). Mean age of the patients with benign GOO was 48.8 ± 14.3 years. Patients with malignant GOO had a mean age of 68.9 ± 10.8 years.
|Figure 1: Age and sex distribution of gastric outlet obstruction patients|
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Clinical presentation of gastric outlet obstruction
Nonbilous vomiting and epigastric pain occurred in 96.2% (50 patients) while 94.2% (49) of patients had weight loss [Table 1]. Twenty-five patients (48.1%) were anemic and required transfusion. Nutritional and electrolyte abnormalities occurred in 71.2% (37) of the patients.
The mean duration of symptoms was 10.5 ± 12.1 weeks.
Upper gastrointestinal endoscopy and biopsy were performed in 48 patients (92.3%). Findings on endoscopy include distended/hypertrophied stomach with pooling of debris and inability to access the first part of the duodenum (from significant scarring in chronic duodenal ulcer/pyloric stricture and deformed pylorus due to exophytic mass/malignant ulceration in malignancy).
Barium meal and follow-through were done in 20 patients (38.5%). Findings on contrast studies include distended and hypertrophied stomach with pooling of contrast, food debris due to deformed pylorus/marked cicatrization of the duodenal bulb in chronic duodenal ulcer [Figure 2]a and [Figure 2]b, and irregular filling defect/shouldering in malignancy.
|Figure 2: (a and b) Barium meal (a) and follow-through (b) showing markedly distended stomach down to the pelvis with pooling of contrast, food debris, and complete cutoff of contrast due to marked cicatrization of the duodenal bulb|
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Causes of gastric outlet obstruction
Malignant obstructions (33 patients, 63.5%) were more common than benign [Table 2]. Antral cancer was the most common cause (29 patients, 55.8%) of GOO. Two patients (3.8%) had GOO from a pyloric stricture postcorrosive ingestion.
Operative intervention in gastric outlet obstruction
Open palliative by-pass for advanced tumors was the most common operation (29 patients, 58.0%) [Figure 3]. All patients with chronic duodenal ulcer had truncal vagotomy and drainage (15 patients, 30.0%). Six patients (12.0%) with malignant GOO had Billroth II procedure (partial gastrectomy with gastrojejunostomy). None had endoscopic stenting.
|Figure 3: Operative intervention of gastric outlet obstruction patients in the University of Benin Teaching Hospital the University of Benin Teaching Hospital|
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One in three patients (17 patients, 34.0%) had postoperative complications [Figure 4]. Surgical site infection alone contributed to eight patients (16.0%).
Duration of hospital stay
The mean duration of hospital stay was 19.7 ± 3.7 days, ranging 16–23 days.
The overall mortality rate was 3.8% (2 patients). All occurred in malignant obstructions.
| Discussion|| |
Management of GOO is a contemporary surgical challenge in developing country/low-resource setting. It constituted 7.9% (52 patients) of 659 gastrointestinal conditions requiring surgery during the study period. An average incidence of 10 cases/year was seen by the authors. This is similar to that reported by other series.,,
There was a male preponderance with a male-to-female ratio of 1.7:1. Ansari et al. reported similar findings, while other studies reported higher ratios.,,,,
The overall cluster age distribution was the 7th–8th decade (33 patients, 63.5%) in the study. However, the female cluster was one decade younger. The mean age for males was 65 ± 14.1 years while that for females was 62.9 ± 11.8 years. Other studies also reported predominance of GOO among the elderly.,,
Three cardinal clinical features were nonbilous vomiting, epigastric pain (96.2%, 50 patients respectively), and weight loss (94.2%, 49 patients) occurred in majority of the patients. Similar findings were reported by other researchers.,,, Of clinical import was our observation that three out of every five patients had more than five clinical features at presentation. These features include epigastric pain, nonbilous vomiting, weight loss, and nutritional and electrolyte abnormalities. These patients who had more than five clinical features at presentation commonly had malignant obstructions.
Nutritional and electrolyte abnormalities occurred in 71.2% (37) of the patients. We observed that this was secondary to late presentation, protracted vomiting in a setting of inanition of GOO. It was a major preoperative challenge. Other studies reported similar findings., Twenty-five patients (48.1%) were anemic and required transfusion. The anemia was due to inadequate nutrition and occult gastrointestinal hemorrhage. During the study period, fresh blood, intravenous fluids were commonly used to optimize the patients by the authors because total parenteral nutrition (TPN) was not easily available/affordable. Six patients (11.5%) had feeding tube jejunostomies with blenderized local diet (examples include blenderized Eba and Egusi sauce or rice and stew) for preoperative correction of nutritional and electrolyte derangements. It is the authors' opinion that this should be advocated in a low-resource setting where TPN is either not available or affordable.
Malignant obstruction (63.5%, 33 patients) was more common than benign obstruction (36.5%, 19 patients). Similar findings have been reported by other authors.,,,,,,,, Antral adenocarcinoma (29 patients, 55.8%) was the most common cause of the malignant obstruction of GOO in our study, unlike other reports., The most common benign cause of GOO was chronic duodenal ulcer (17 patients, 32.7%), most of this occurred in the patients who chronically used/abused nonsteroidal anti-inflammatory drug to treat body aches from their manual farm work , and subsequently developed duodenal ulcer. GOO from benign causes was noted more in the middle aged (mean age of 48.8 ± 14.3 years) while malignant causes predominated in the elderly (mean age of 68.9 ± 10.8 years). Presentations were late (mean duration of symptoms - 10.5 ± 12.1 weeks), and preoperative gastric atony (57.7%), nasogastric tube drainage (100%), gastric lavage of food debris (100%), and correction of electrolyte derangements (71.2%) increase hospital stay.
Surgical intervention was effected in 50 patients (96.2%). These patients had pyloric obstruction from the mass effect of tumors or severe scarring from chronic peptic ulcer disease, which required relief by surgical intervention. Several studies worldwide reported similar surgical intervention rates ranging from 91% to 98%.,, Two patients (3.8%) did well on nonsurgical management (fluid and electrolyte resuscitation, nasogastric drainage, nutritional rehabilitation, antibiotics, and proton pump inhibitors) and were discharged without surgical intervention. These patients had GOO from peptic ulcer disease. Their obstruction was probably secondary to pyloric spasm and edema, which is reversible on adequate and appropriate nonoperative treatment.
GOO from postcorrosive stricture was rare in our study (2 patients, 3.8%). Its incidence in our study is 0.4 cases/year similar to other reports.,, It occurred in patients who had ingested acid in an attempt to commit suicide. Both patients of clinical note had no premorbid psychiatric illnesses. The patients were treated via bypass gastrojejunostomy procedures., Fifty-eight percent (29 patients) of all malignant obstructions were inoperable and had palliative bypass. Only 12.0% (6 patients) of malignant GOO had resectable tumors – palliative distal gastrectomy (Billroth II). This intervention is in keeping with other African studies., None of the patients had endoscopic stenting due to lack of facilities for the procedure. Late presentation was common. This could be as a result of the abuse/over-the-counter prescriptions by nonspecialists of antiulcer medication without proper diagnosis, ignorance about disease, and unavailability/affordability of routine upper gastrointestinal endoscopy and biopsy for epigastric pains in a low-resource setting.,, All patients with GOO from chronic duodenal ulcer, in this study, had truncal vagotomy and gastrojejunostomy because of the severely cicatrized duodenum from late presentation. Triple by-pass was performed in this study for patients with GOO from inoperable carcinoma of the head of the pancreas with associated obstructive jaundice.
During the study period, the crude postoperative complication rate was 34.0% (17 patients). Surgical site infection was the most common complication (16.0%, 8 patients). Jaka et al. reported a similar finding in Tanzania while Kotisso  reported dumping syndrome as the most common complication of GOO in Ethiopia.
In our study, we found that the hospital stay ranged between 16 and 23 days, with a mean duration of 19.7 ± 3.7 days. This is similar to reports of other studies., Probably, the prolonged hospital stay was secondary to late presentation to the hospital, the poor clinical state of the patients at presentation with fluid, electrolyte, and nutritional abnormalities which required prolonged preoperative corrective procedures. This correction was achieved using preoperative nasogastric tube suction, warm saline lavage, intravenous fluids, blood transfusion, and rarely feeding tube jejunostomy with blenderized local African feeds.
Mortality rate during the study period was 3.8% (2 patients). It occurred in patients who had advanced malignant GOO. This in-hospital mortality rate is much lower than that reported by other workers., This could be attributed to aggressive preoperative resuscitation, blenderized feeding, and optimization of patients before surgery. The authors advocate this before elective operations of these patients.
| Conclusions|| |
In the South-South region of Nigeria, GOO is a disease of the elderly. Malignant obstruction is contemporarily, the most common cause of GOO in our region. Presentation is late. Nine of ten GOO patients require surgical intervention to relieve the obstruction. Aggressive, adequate, preoperative resuscitation/optimization of these chronically ill patients improves outcome. This is advocated for GOO patients by the authors. There is a need for early referral to a specialist and routine endoscopy and biopsy for patients with epigastric pain, in our subregion.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Way LW, editor. Stomach and duodenum. In: Current Surgical Diagnosis and Treatment. 10th
ed. Norwalk, CT: Appleton and Lange; 1994. p. 437-59.
Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: A systematic review. BMC Gastroenterol 2007;7:18.
Jaka H, Mchembe MD, Rambau PF, Chalya PL. Gastric outlet obstruction at Bugando medical centre in Northwestern Tanzania: A prospective review of 184 cases. BMC Surg 2013;13:41.
Appasani S, Kochhar S, Nagi B, Gupta V, Kochhar R. Benign gastric outlet obstruction – Spectrum and management. Trop Gastroenterol 2011;32:259-66.
Kabuyaya MK, Ssebuufu R, Asiimwe-Kateera B, Nyundo M, Rickard J. Gastric outlet obstruction among adult patients at two Rwandan referral hospitals: Etiology, H. pylori
infection and outcomes. East Central Afr J Surg 2015;20:62-8.
Kotisso B. Gastric outlet obstruction in Northwestern Ethiopia. East Central Afr J Surg 2007;5:25-9.
Samad AK, Khanzada TW, Shoukat I. Gastric outlet obstruction: Change in etiology. Pak J Surg 2007;23:29-32.
Kumar PN, Lakshmi RM, Karthik GS. A clinicopathological study on gastric outlet obstruction in adults. J Evol Med Dent Sci 2017;6:382-6.
Dogo D, Yawe T, Gali BM. Gastric outlet obstruction in Maiduguri. Afr J Med Med Sci 1999;28:199-201.
Shone DN, Nikoomanesh P, Smith-Meek MM, Bender JS. Malignancy is the most common cause of gastric outlet obstruction in the era of H2 blockers. Am J Gastroenterol 1995;90:1769-70.
Baitchev G, Hristova P, Ivanov I. Surgical treatment of gastric outlet obstruction. Khirurgiia (Sofia) 2009;6:23-6.
Ansari MM, Haleem S, Harris SH, Khan R, Zia I, Beg MH. Isolated corrosive pyloric stenosis without oesophageal involvement: An experience of 21 years. Arab J Gastroenterol 2011;12:94-8.
Gibson JB, Behrman SW, Fabian TC, Britt LG. Gastric outlet obstruction resulting from peptic ulcer disease requiring surgical intervention is infrequently associated with Helicobacter pylori
infection. J Am Coll Surg 2000;191:32-7.
Sukumar V, Ravindran C, Prasad RV. Demographic and etiological patterns of gastric outlet obstruction in Kerala, South India. N Am J Med Sci 2015;7:403-6.
Misra SP, Dwivedi M, Misra V. Malignancy is the most common cause of gastric outlet obstruction even in a developing country. Endoscopy 1998;30:484-6.
Johnson CD. Gastric outlet obstruction malignant until proved otherwise. Am J Gastroenterol 1995;90:1740.
Søreide K, Thorsen K, Harrison EM, Bingener J, Møller MH, Ohene-Yeboah M, et al.
Perforated peptic ulcer. Lancet 2015;386:1288-98.
Agbonrofo PI, Irowa OO, Okhakhu AL, Odigie VI, Oboh OE, Eriba LO, et al
. Seasonal variation of gastro – Duodenal perforation in university of Benin teaching hospital (UBTH)- A 5-year study. Clin Surg 2018;3:2064.
Jaffin BW, Kaye MD. The prognosis of gastric outlet obstruction. Ann Surg 1985;201:176-9.
Weiland D, Dunn DH, Humphrey EW, Schwartz ML. Gastric outlet obstruction in peptic ulcer disease: An indication for surgery. Am J Surg 1982;143:90-3.
Lebeau R, Coulibaly A, Kountélé Gona S, Koffi Gnangoran M, Kouakou B, Yapo P, et al.
Isolated gastric outlet obstruction due to corrosive ingestion. J Visc Surg 2011;148:59-63.
Onotai LO, Nwogbo AC. Pattern of corrosive ingestion injuries in Port Harcourt: A ten year review. Niger Health J2010;10:22-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]